RU2455943C1 - Method of treating obturative form of acute adhesive obstruction of small intestine - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, abdominal surgery, treatment of obturative form of acute adhesion obstruction of small intestine (OFAAOSI). In patient with clinical presentation of OFAAOSI the following parameters are estimated in points: duration of period from onset of disease till admission to hospital, number of operations on abdominal cavity organs in anamnesis, intensity and character of pain in region of abdomen, level of obstruction, small intestine diameter, body temperature, pulse, content of potassium in blood serum. Obtained points are summed up and further tactics of management is selected depending on said sum. If it constitutes less than "-8" points, urgent operation is performed. If sum of points is more than "10", conservative therapy, which includes correction of metabolic disorders, decompression of lower parts of gastrointestinal tract (GIT), is carried out. If sum of points is between "-8" to "10" carrying out correction of metabolic disorders and decompression of lower parts of (GIT) is supplemented with endoscopic nasointestinal decompression. If therapy is inefficient, surgery is performed within 12 hours.

EFFECT: method ensures objectivisation of indications for operative or conservative treatment in said group of patients, prevention of post-operative complications, reduction of hospitalisation terms.

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Description

The invention relates to medicine, namely to abdominal surgery, and can be used in the treatment of acute adhesive small bowel obstruction.

With the obstructive form of acute commissural small bowel obstruction (OFOSTKN), it is logical for the surgeon to avoid difficult and often difficult surgical intervention and resolve it with conservative measures, including using the modern method - endoscopic nasointestinal decompression (ENID), which has shown high efficiency in this pathology.

On the other hand, delaying the terms of surgical treatment in case of ineffectiveness of the therapy is associated with an increase in the number of complications and mortality. Delaying the terms of surgical treatment in case of ineffectiveness of the therapy is accompanied by a rapid deepening of metabolic disorders, an increase in the likelihood of destructive changes in the small intestine and an increase in mortality (Savelyev B.C., 2005, Williams S.B, 2008).

In this regard, the objectification of evidence and the reasonable conduct of conservative measures aimed at resolving OFOSTKN are relevant.

A known method of treatment of OFOSTKN, which consists in predominantly surgical treatment after short-term conservative therapy (Silen W., 1962, Norenberg-Charkviani A.E., 1969, M.M. Vinokurov, 1999, Fevang V.T., 2004). The disadvantage of this method is the performance of an excessive number of operations, which inevitably leads to postoperative complications (inconsistency of intestinal anastomoses, prolonged postoperative ileus, sepsis, relapse OFOSTKN, wound infectious complications, as well as non-surgical complications - cardiogenic, infectious and others), to prolong the period of hospitalization.

A known method of treatment OFOSTKN, which consists in the maximum use of conservative methods (Nauta R.J., 2005). The disadvantage of this method is the risk of missed strangulation - about 4% according to Nauta R.J., 2005, delaying the time of surgical intervention and, as a rule, the more severe general condition of the patient if conservative therapy is ineffective.

The method of treatment described by Petrov V.P. is closest to solving the problem. (Petrov V.P., Eryukhin I.A. Acute intestinal obstruction, 1999), which consists in the fact that, based only on the clinical picture of the patient, differentially apply a conservative or surgical method of treatment, and conservative treatment is used for 2-3 days, and then with its inefficiency surgery is performed. The disadvantage of this method is the lack of clear indications for the use of one or another treatment method.

We set the task - to develop a treatment method for OFOSTKN that takes into account a set of generally accessible clinical, laboratory and instrumental studies in order to implement a differentiated approach to the choice of the resolution method of OFOSTKN (operational, conservative).

The technical result consists in the prevention of postoperative complications, reducing the time of hospitalization of patients with OFOSTKN by eliminating unreasonable surgical interventions by means of a differentiated approach to the treatment of OFOSTKN taking into account the results of a complex of simple, accessible clinical and instrumental studies; providing the opportunity to choose the optimal method of treatment in the early stages from the moment of admission of patients.

Thus, the use of a complex of simple and affordable clinical, laboratory and instrumental studies already in the early stages allows, on the one hand, to determine the indications for emergency surgery and, on the other hand, to exclude unreasonable surgical intervention.

To solve this problem, a method for the treatment of patients with OFOSTKN has been developed, which consists in a differentiated approach to the choice of a conservative or surgical method of treatment in the required volume, depending on the clinical, laboratory and instrumental data. We have proposed a complex of nine parameters, based on which it is possible to choose the optimal treatment method.

The invention consists in the following.

The following indicators are determined in a patient: the length of the period from the onset of the disease to admission to the hospital, the number of operations on the organs of the abdominal cavity in the anamnesis, the intensity and nature of pain in the abdomen, the level of obstruction, the diameter of the small intestine, body temperature, pulse, and the content of potassium in blood serum .

The scoring of indicators is presented in the table.

Indicator Value K Duration from onset to admission Up to 36 hours one 36-72 h -2 > 72 h -5 History of operations 0 -5 one -one 2 and more +1 Pain intensity Moderate +1 Intense -5 Nature of pain Cramping +7 Constant -four Obstruction Level High or medium +3 Low -one Small intestine diameter <40 mm +3 ≥40 mm -3 Body temperature <37 ° C +1 ≥37 ° C -3 Pulse (bpm) <85 +1 ≥85 -3 The level of potassium in the blood (mmol / l). 3,5-5,0 -3 > 5.0 -four <3,5 +2

Conduct a score on 9 of these indicators as follows:

- the duration of the period from the onset of the disease to admission to the hospital is less than 36 hours - “1” point, from 36 to 72 hours - “-2” points and over 72 hours - “-5” points;

- the absence of operations on the organs of the abdominal cavity in the anamnesis - “-5” points, the presence of one such operation - “-1” point, the presence of two or more such operations on the organs of the abdominal cavity in the anamnesis - “1” point;

- moderate pain in the abdomen - "1" point, intense pain in the abdomen - "-5" points;

- cramping pain in the abdomen - "1" point, constant pain in the abdomen - "-4" points;

- high or medium level of obstruction - “3” points, low level of obstruction - “-1” point;

- the diameter of the small intestine is less than 40 mm - "3" points, equal to or more than 40 mm - "-3" points;

- body temperature less than 37 ° C - "1" point equal to or higher than 37 ° C - "-3" point;

- pulse less than 85 beats per minute - “1” point, equal to or more than 85 beats per minute - “-3” points;

- serum potassium content from 3.5 to 5.0 mmol / L - “-3” points, more than 5.0 mmol / L - “-4” points, less than 3.5 mmol / L - “2” points .

The points of all assessed indicators are summarized, and if the total score is less than "-8", then they perform emergency surgery aimed at resolving obstruction. If the total score is more than "+10", then conservative therapy is carried out, including the correction of metabolic disorders, decompression of the lower parts of the gastrointestinal tract. With a score of “-8” to “+10”, conservative therapy is carried out, including the correction of metabolic disorders, decompression of the lower gastrointestinal tract, which is supplemented by endoscopic nasointestinal decompression, and if the therapy is ineffective, surgery is performed within 12 hours.

The method is as follows.

Patients with suspected OFOSTKN coming to the clinic on an emergency basis were examined according to the generally accepted plan:

1) anamnesis;

2) collection of complaints;

3) data from a physical examination (surgical status);

4) laboratory tests (clinical blood test, acid-base state of the blood (KHS);

5) survey radiography of the abdominal cavity for intestinal levels.

After the diagnosis was established - acute commissural small bowel obstruction, obstructive form - an assessment was made in points according to the selected 9 parameters. Patients with a strangulated form of acute commissural small bowel obstruction were excluded from further examination and operated on an emergency basis.

Each of the parameters of the patient's condition was assigned points.

Next, the scores of all 9 evaluated indicators were summarized and the treatment volume was determined as follows:

if the total score was less than "-8", then they performed emergency surgery aimed at resolving obstruction;

if the total score was more than +10, then conservative therapy was carried out, including the correction of metabolic disorders, decompression of the lower parts of the gastrointestinal tract;

with a score from “-8” to “+10”, conservative therapy was carried out, including correction of metabolic disorders, decompression of the lower gastrointestinal tract, which was supplemented by endoscopic nasointestinal decompression, and if the therapy was ineffective, surgery was performed for 12 hours.

To prove the possibility of realizing the claimed purpose and achieving the specified technical result, we provide the following data.

The effectiveness of the method was tested on 43 patients included in a prospective study. After a preliminary clinical and laboratory diagnosis and diagnosis of OFOSTKN, for each patient, the total score is determined according to table 1. This allowed us to formulate the indications for treatment in the required amount.

In 12 patients, the total score was less than “-8", clinical, laboratory and instrumental data in these patients showed a pronounced character of small bowel obstruction. All these patients were operated on without attempting conservative resolution after short-term preoperative preparation. Intraoperatively, all patients showed pronounced small bowel obstruction with significant dilatation of the small intestine (more than 40 mm), signs of reversible malnutrition of the intestinal wall in 2 patients and 5 patients — a large amount of discharge through the nasointestinal probe during surgery (more than 1 liter), which indicated about decompensation of the function of the small intestine. In all cases, intraoperative findings confirmed the need for emergency intervention. Lethal outcomes and complications in this group were not noted.

In 16 patients, the total score was more than “-8” and less than “+10", in these patients water-electrolyte disturbances of moderate severity were noted. Conservative therapy aimed at correcting metabolic disorders was performed, all patients underwent ENID. The average duration of conservative events in this group was 16 ± 4.2 hours. The effect of conservative therapy was observed in 11 of 16 patients (68.7%). 5 patients were operated on urgently due to the ineffectiveness of conservative therapy. Intraoperatively, they showed no signs of malnutrition of the wall or signs of neglected intestinal obstruction.

In 15 patients, the total score was more than "+10" points, the severity of intestinal obstruction according to clinical, laboratory and instrumental data was minimal. A positive effect of conservative therapy was observed in all 15 patients. On average, the term for permitting OFOSTKN was much shorter than in the second group, and amounted to 8.6 ± 3.2 hours.

In the study group (43 patients) not a single fatal outcome was noted.

There were also no cases of delayed surgical intervention. The average operation time was 12.5 ± 3.4 hours from the time of receipt.

The proposed method can be explained on the following specific clinical examples.

1. Example: Patient J., 38 years old (I.B. 20478/2009), was admitted with the clinical picture of acute commissural small bowel obstruction 9 hours after the onset of the disease.

Complaints of moderate cramping abdominal pain, nausea, dry mouth, bloating.

From the anamnesis: the patient underwent appendectomy from access according to Volkovich-Dyakonov and twice laparotomy for acute commissural small bowel obstruction.

Objectively: the stomach is swollen, symmetrical, participates in the act of breathing. During auscultation, peristalsis is somewhat enhanced, without a resonating component, "splashing noise" is not clearly heard. With percussion, tympanitis of percussion sound in the upper sections is determined, blunting in sloping places is not detected. On palpation, the abdomen is soft, moderately painful in mesogastrium. Body temperature 36.7 ° C, pulse 84 beats. in minutes According to laboratory data, the potassium content in the blood serum is 2.0 mmol / L.

An abdominal x-ray shows signs of small bowel obstruction of an average level of localization: multiple horizontal levels of fluid with air arches in the mesogastric region. The diameter of the intestine according to x-ray data up to 40 mm.

Preliminary clinical diagnosis: acute adhesive small bowel obstruction, obstructive form.

To determine the volume of treatment, the proposed method was used as follows: scores were calculated for each of the nine signs in accordance with the methodology.

1. The time from the onset of the disease to admission is up to 36 hours (+1 point).

2. The history of operations is three (+1 point).

3. The intensity of the pain is moderate (+1 point).

4. The nature of the pain is cramping (+1 points).

5. The level of obstruction is average (+3 points).

6. The diameter of the small intestine is up to 40 mm (+3 points).

7. Body temperature - 36.7 ° C (+1 point).

8. Pulse - 84 beats per minute (+1 point).

9. The level of potassium in the blood - 2.0 mmol / l (+2 points).

The total score for the patient was +14 points.

The patient underwent conservative therapy aimed at correcting metabolic disorders, decompression of the lower parts of the gastrointestinal tract, and underwent dynamic observation. Conducted conservative therapy with a positive effect, the occurrence of intestinal obstruction resolved. When control x-ray signs of obstruction were not detected.

On the 9th day after the operation, the patient was discharged for outpatient aftercare.

2. Example: Patient M., 39 years old (ib 24282/2009 year), was admitted with the clinical picture of acute commissural small bowel obstruction after 64 hours from the onset of the disease.

Complaints of moderate cramping pains in the epigastrium, bloating, difficulty in gas discharge, nausea.

From the anamnesis: the patient underwent laparoscopic cholecystectomy and laparoscopic appendectomy, surgery for an ectopic pregnancy on the left.

Objectively: the stomach is swollen, symmetrical, participates in the act of breathing. With auscultation of intestinal motility of normal sonority, there is no “splash noise”. With percussion, dullness in sloping places was not detected. On palpation, the abdomen is soft, moderately painful in the navel, in the mesogastric region. Muscle tension of the anterior abdominal wall was not detected. According to laboratory data, the potassium content in the blood serum is 4.9 mmol / L.

With a panoramic radiography of the abdominal cavity, signs of small bowel obstruction of an average level of localization: a single level of fluid in the small intestine, moderate pneumatosis of the small intestine. The diameter of the intestine according to x-ray data up to 25 mm.

Preliminary clinical diagnosis: acute adhesive small bowel obstruction, obstructive form.

To determine the volume of treatment, the proposed method was used as follows: scores were calculated for each of the nine signs in accordance with the methodology.

1. The time from the onset of the disease to admission is from 36 to 72 hours (-2 points).

2. The history of operations is three (+1 point).

3. The intensity of the pain is moderate (+1 point).

4. The nature of the pain is cramping (+1 points).

5. The level of obstruction is average (+3 points).

6. The diameter of the small intestine is up to 40 mm (+3 points).

7. Body temperature - 36.7 ° C (+1 point).

8. Pulse - 84 beats per minute (+1 point).

9. The level of potassium in the blood is 4.9 mmol / l (-3 points).

The patient’s total score was +6 points.

The patient underwent conservative therapy aimed at correcting metabolic disorders. ENID was performed, 200 ml of stagnant contents were obtained from the probe. Against the background of the therapy, the effects of intestinal obstruction resolved. During the control probe radiography after 6 hours, the contrast medium entered the initial sections of the colon.

On the 9th day after admission, the patient was discharged for outpatient aftercare.

Thus, the proposed treatment method allows a differentiated approach to the choice of the volume and nature of conservative therapy

3. Example: Patient V., 41 years old (ib. 2189/2009 year), was admitted with a clinical picture of acute commissural small bowel obstruction 54 hours after the onset of the disease.

Complaints of constant pain in the epigastrium of moderate intensity, bloating, chills, nausea, delayed discharge of gases.

From the anamnesis: the patient underwent surgery for intussusception of intestinal obstruction in childhood, appendectomy.

Objectively: the stomach is swollen, symmetrical, participates in the act of breathing. With auscultation of intestinal motility of increased intensity, there is no “splashing noise”. With percussion, dullness in sloping places is determined. On palpation, the abdomen is soft, painful in the epigastrium. Muscle tension of the anterior abdominal wall was not detected. Gases do not escape. According to laboratory data, the potassium content in the blood serum is 2.9 mmol / L.

An abdominal x-ray shows signs of low small bowel obstruction: multiple levels of fluid in the small intestine. The diameter of the intestine according to x-ray data up to 80 mm.

Preliminary clinical diagnosis: acute adhesive small bowel obstruction, obstructive form.

To determine the volume of treatment, the proposed method was used as follows: scores were calculated for each of the nine signs in accordance with the methodology.

1. The time from the onset of the disease to admission is from 36 to 72 hours (-2 points).

2. The number of operations in history - 2 (+1 point).

3. The intensity of the pain is moderate (+1 point).

4. The nature of the pain is constant (-4 points).

5. The level of obstruction is low (-1 points).

6. The diameter of the small intestine is more than 40 mm (-3 points).

7. Body temperature - 37.1 ° C (-3 points).

8. Pulse - 88 beats per minute (-3 points).

9. The level of potassium in the blood is 2.9 mmol / l (+2 points).

The patient’s total score was “-12” points.

The patient underwent intensive preoperative preparation. An emergency laparotomy was performed. During the audit - in the abdominal cavity 200 ml of odorless effusion, the intestine is stretched to 8 cm, peristalsis is weakened, the wall is swollen. In the projection of the mesentery, a single extrusion is determined that has been dissected. The intestine is viable throughout, the peristalsis is preserved, the pulsation of the vessels is distinct.

The postoperative period was uneventful, on the 11th day the patient was discharged for outpatient aftercare.

Thus, despite the unexpressed clinical picture, taking into account the proposed method, indications for the operation were established, operational findings confirmed the correctness of the choice of treatment method, which was confirmed during the operation.

Timely integrated assessment of the patient's condition made it possible to optimally choose the volume of treatment in the described cases.

Of the 43 patients with the highest sensitivity (100%), patients with OFOSTKN who were shown emergency surgical treatment were selected at the initial examination stage.

Patients received conservative therapy in a differentiated volume. Noteworthy is the absence of advanced cases of OFOSTKN among patients operated upon after unsuccessful conservative therapy.

The created diagnostic algorithm allows us to choose the most effective and safe treatment method for patients with OFOSTKN already at the stage of the initial examination.

Using the described method of treatment allows a differentiated approach to the choice of treatment volume with OFOSTKN, to objectify indications for surgery, improve treatment results, and reduce mortality. For comparison, the mortality rate in published studies of patients with OFOSTKN is 2.4-7.1% (Petrov V.P., 1999, Fevang V.T., 2004, Williams S.B., 2008).

The presented method of treatment has significant novelty and allows you to choose the volume of treatment without the use of special research methods that require expensive equipment. It can be used in hospitals that provide emergency and urgent surgical care around the clock.

The method was tested in the city clinical hospital No. 31 and is currently required in our practice in determining the surgical management of patients with OFOSTKN.

Claims (1)

A method of treating an obstructive form of acute commissural small bowel obstruction, characterized in that the patient determines the following indicators: the length of the period from the onset of the disease to admission to the hospital, the number of operations on the abdominal organs in the anamnesis, the intensity and nature of pain in the abdomen, obstruction, diameter small intestine, body temperature, pulse, serum potassium content; each of these indicators is expressed in points, evaluating them as follows: the duration of the period from the onset of the disease to admission to the hospital is less than 36 hours - “1” point, from 36 to 72 hours - “-2” points and over 72 hours - “-5 "Points; the absence of operations on the organs of the abdominal cavity in the anamnesis - “-5” points, the presence of one such operation - “-1” point, the presence of two or more such operations on the organs of the abdominal cavity in the anamnesis - “1” point; moderate pain in the abdomen - “1” point, intense pain in the abdomen - “-5” points; cramping pain in the abdomen - “1” point, constant pain in the abdomen - “-4” points, high or medium level of obstruction - “3” points, low level of obstruction - “- 1” point; the diameter of the small intestine less than 40 mm - "3" points, equal to or more than 40 mm - "-3" points; body temperature less than 37 ° C - “1” point, equal to or higher than 37 ° C - “-3” point; pulse less than 85 beats per minute - “1” point, equal to or more than 85 beats per minute - “-3” points; serum potassium content from 3.5 to 5.0 mmol / L - “-3” points, more than 5.0 mmol / L - “-4” points, less than 3.5 mmol / L - “2” points; after which the scores of all evaluated indicators are summarized and, if the total score is less than "-8", an emergency surgery is performed, if the total score is more than "10" conservative therapy is carried out, including correction of metabolic disorders, decompression of the lower gastrointestinal tract, and with a score from “-8” to “10”, conservative therapy, including correction of metabolic disorders, decompression of the lower gastrointestinal tract, is supplemented by endoscopic nasointestinal decompression ssiey and in case of failure of therapy for 12 hours perform surgery.